Laboratory Communications

11/11/2022- Service update: Resumption of testing for folate, urinary albumin
Reagent stocks are now replenished for both our folate and urinary albumin (microalbumin) tests and service is now running as normal. Folate requests were being sent to a third party lab and were continuously processed throughout the reagent shortage. For microalbumin samples, these were stored frozen and we have now cleared the backlog, and all results are now available. There were a very small number where samples were not saved or otherwise lost and reports issued to this effect. Turn-around times should now be back to those seen prior to the issues with non-availability of reagent. We apologise for the inconvenience this may have caused.

11/11/2022- Service update: ACCP test
Reagent unavailability means that we are presently unable to analyse samples for anti-cyclic citrullinated peptide antibodies (ACCP). We anticipate that reagents will once again be available within the coming week. However, this does mean there will be longer than expected turn-around times in the interim. We apologise for any inconvenience this may cause.

28/09/2022- Critical reagent shortage: urinary albumin

Dear colleagues,

Due to circumstances beyond our control, we are temporarily unable to analyse samples for urinary albumin (microalbumin). We expect that further reagent will be available in early October. Please note that samples will be stored frozen and there will be delays in turn-around time for this assay with the assurance that results will be available once reagent supply is restored.

Where possible, we advise that urine sample collection for albumin analysis should be delayed until reagent supply is restored.

We apologise for the inconvenience. If you wish to discuss this or any other issue related to lab service, please contact the Duty Biochemist.

 26/09/2022- Critical reagent shortage – Lithium

Due to a critical reagent issue beyond our control, lithium analysis is not available at Barnsley or Rotherham laboratories. With immediate effect, all requests for serum lithium will be sent to an external laboratory (Sheffield Teaching Hospital). The therapeutic/reference range is unchanged, however users may see an increased turn-around time. If there is any clinical suspicion of toxicity and an urgent result is required, please contact the laboratory to arrange rapid sample processing. Please accept our apologies for any inconvenience this may cause.

For further information or discussion, please contact the Duty Biochemist or contact iain.woodrow@nhs.net or via extension 5749 (01226 435749 if external).

05/09/2022- Critical reagent shortage- Carbamazepine

Our reagent suppliers have informed us that there is a critical national shortage of reagents for our carbamazepine assay. We are making contingency plans to allow us to continue to provide this test, likely involving sending requests to a third-party laboratory.

However, this is likely to have some impact on current turn-around times for this assay.

Consequently, can we please ask that, in the interim, requests for this drug are only sent when clinically indicated (most notably when there is a suspicion of toxicity or non-adherence), and not for routine monitoring purposes.

Current estimates from our reagent manufacturer is that stock may be restored in early November.

If you would like further information or wish to discuss this assay or anything else, please do not hesitate to contact Dr Iain Woodrow iain.woodrow@nhs.net 01226 435749 or the laboratory at Barnsley or Rotherham

24/08/2022- UPDATE- Critical Folate reagent shortage now until late-October: please only request if clinically indicated

Due to a further acute national reagent shortage, we would ask that users please only measure folate where there is an acute clinical need. Please also consider whether any test requests for folate could be delayed until reagent supply is restored (currently anticipated in mid-late October).

We are likely to completely exhaust our reagent stock and resort to testing at an laboratory from early September onwards. We plan to send folate requests to Sheffield Teaching Hospitals Laboratory in this event.

Please note that turn-around times for folate results may be longer as the test may need to be performed in batches to conserve reagent. Turnaround times are likely to exceed 24 hours once samples are being sent to Sheffield for analysis. We apologise for any inconvenience this may cause.

As an aid, see below a summary of the indications of where haematinic requesting may be indicated. Please note this is not exhaustive and for guidance only.

Indications for haematinics requesting:

Please contact the laboratory if you have any further questions.

30/05/2022- Critical Folate reagent shortage until mid-July: please only request if clinically indicated

Due to an acute national reagent shortage, we ask that clinicians please only measure folate where there is an acute clinical need. Please also consider whether any test requests for folate could be delayed until reagent supply is restored (currently anticipated in mid-July).

We are likely to completely exhaust our reagent supply and require external testing from mid-June onwards. We plan to send folate requests to Sheffield Teaching Hospitals Laboratory in this event.

Please note that turn-around times for folate results may be longer as the test may need to be performed in batches to conserve reagent. Turnaround times are likely to exceed 24 hours once samples are being sent to Sheffield for analysis. We apologise for any inconvenience this may cause.

As an aid, see below a summary of the indications of where haematinic requesting may be indicated. Please note this is not exhaustive and for guidance only.

Indications for haematinics requesting:

Suggested indications for B12 + Folate:

1.     Macrocytic anaemia

2.     Peripheral neuropathy

3.     Oral ulceration

4.     Unexplained cerebral decline

5.     Anaemia and hypothyroidism

6.     Anaemia and thrombocytopenia or neutropenia

Suggested indications for B12 + folate + ferritin:

1.     Unexplained normochromic normocytic anaemia

2.     ?malabsorption

3.     Anaemia and poor diet

Please contact the laboratory if you have any further questions.

10/05/2022 – Cortisol assay: cross-reactivity with Prednisolone

Please be reminded that there is significant cross-reactivity in our cortisol assay with many synthetic glucocorticoids, particularly prednisolone. Please be aware that when undertaking any investigations involving measuring cortisol in patients on prednisolone (including dynamic function tests), the measured result will have a significant positive bias and be unlikely to reflect the concentration of the native hormone. Please contact the lab for further advice or discussion

01/04/2022- Critical FT4 reagent shortage: change to test availability and turn-around times
 
Due to an acute national reagent shortage, FT4 will only be measured on samples with an abnormal TSH from Monday 4 April. FT4 will not be available to request directly from ICE, Meditech or via paper requests, but will be automatically added in the laboratory to samples with an abnormal TSH result.
If there is a strong clinical need for FT4 analysis on your patient, please contact the biochemistry laboratory directly.
 
Please note that turn-around times for FT4 results will be longer as the test will only be performed at Barnsley laboratory (as of 31.03.22), with weekend samples being batched for one analytical run on Sunday, except for clinically urgent requests 
 
This is a temporary measure and we hope to resume our normal procedure as soon as reagent stocks are back to normal. We apologise for any inconvenience this may cause.

14/12/2021- Digoxin Changes

From 20/12/21 we will be updating our quoted therapeutic range for digoxin to: 0.7 – 2.0 ug/L.

This revised therapeutic range brings us in line with the NICE Clinical Guideline for Atrial Fibrillation (https://cks.nice.org.uk/topics/atrial-fibrillation/prescribing-information/digoxin/).

There will be an accompanying text comment regarding digoxin concentration in patients with heart failure to reflect the narrower therapeutic window in heart failure:

“Therapeutic target of 0.5-1.0 ug/L in heart failure.”

For patients being treated for digoxin toxicity, please note that Digifab interferes with digoxin immunoassays, so there is no clinical benefit in checking digoxin levels after Digifab administration.

14/12/2021- Microbiology Antimicrobial susceptibility interpretation guidance

As from the 11/1/22, the Microbiology department will be reporting antimicrobial susceptibility results as per the updated guidance released by the European Committee on Antimicrobial Susceptibility Testing (EUCAST). The new interpretations are categorised and defined into three susceptibility categories:

1. S - Susceptible, standard dosing regimen: A microorganism is categorised as Susceptible, standard dosing regimen, when there is a high likelihood of therapeutic success using a standard dosing regimen of the agent.  

2. I (High dose) - Susceptible, increased exposure: A microorganism is categorised as Susceptible, increased exposure* when there is a high likelihood of therapeutic success because exposure to the agent is increased by adjusting the dosing regimen or by its concentration at the site of infection.  

3. R - Resistant: A microorganism is categorised as Resistant when there is a high likelihood of therapeutic failure even when there is increased exposure.  

*Exposure is a function of how the mode of administration, dose, dosing interval, infusion time, as well as distribution and excretion of the antimicrobial agent will influence the infecting organism at the site of infection

Please refer to the antimicrobial policy for further information. Alternatively, contact the microbiology department or senior clinical pharmacist if further guidance is required.

29/11/2021- Communication: eGFR and KFRE

In August 2021 NICE published an updated “Chronic kidney disease: assessment and management” guideline (NG203). This includes two new considerations for users of Blood Sciences at BRILS who request tests of renal function:

1) Removing adjustment for ethnicity from eGFR

 The guidance to adjust for ethnicity when calculating the estimated glomerular filtration rate (eGFR) in people from Afro-Caribbean ethnic groups is no longer deemed to be valid.

The NICE Committee agreed that adding an ethnicity adjustment to eGFR equations for different ethnicities is not supported by evidence from available studies, and, because the muscle mass varies widely between individuals within the same ethnicity, the adjustment may not be accurate for all individuals within any given ethnic group

In addition, NICE reiterated that eGFR creatinine may be less reliable in certain situations such as acute kidney injury; pregnancy; oedematous states; muscle wasting disorders; in those who are malnourished, have higher muscle mass, use protein supplements or those who  have undergone amputation. (Please note that although not specifically mentioned in NICE guidance, sports supplements, especially those containing creatine may also make eGFR creatinine interpretation less reliable.)

2) Kidney Failure Risk Equation (KFRE)

There is an update related to assessing the risk of patients with known CKD progressing to require renal replacement therapy.

NICE now suggest that adults with CKD are provided with a risk score, calculated using the 4-variable kidney failure risk equation (KFRE). The equation uses patient age, gender, eGFR and urinary Albumin to Creatinine ratio to calculate the kidney failure risk. The recommendation is that patients are referred for specialist assessment, should their 5 year risk from the calculation be greater than 5%.

The current version of our laboratory information management system (LIMS) is unable to calculate this score, but while we are addressing this, we will provide on ICE and the pathology website a link to the risk calculator on the NICE website. Please use this calculator where appropriate, according to guidance.

 As a result of these updates, from the 29th of November the comment appended to eGFR results on lab reports will be as follows:

“NICE no longer recommend any correction to eGFR for ethnicity. Please interpret with caution in patients with extremes of muscle mass, or other confounding factors. For more info see https://tinyurl.com/4hjbeaac”

There will also be additional code linked to UEs results with the following comment:

“For KFRE calculator refer to: https://www.nice.org.uk/guidance/ng203/resources or a link on ICE.”

23/11/2021- Communication: Sample Transportation Reminder

For all users of BRILS please note that timely transport of samples to the laboratory is important in ensuring sample integrity and subsequent patient results. Can all GP and community users please ensure that samples are transported on the next available collection. Refrigeration of samples prior to collection can also affect sample integrity and may lead to spurious results so please do not store samples in a fridge prior to transport. Please see our user webpage for further information:   https://www.barnsleyhospital.nhs.uk/pathology/pathology-general/transport-spceimens-laboratory/

23/11/2021- Communication: Reminder- Phlebotomy Outpatients 

The Phlebotomy service is now appointment only and appointments can be booked by telephoning 01226 433969 between 8:00 and 16:50 Monday to Friday. Please note that the appointment line is very busy and often patients will have to try multiple times to get through.  We are aware of the difficulties and a solution is being looked into to improve the appointment system. We apologies for any inconvenience caused. 

21/10/2021- Communication: Changes to repeat Biochemistry requests for slightly haemolysed samples

BRILS blood sciences laboratories replaced their automated analysers in Autumn 2020. As a result of feedback from users about the impact that increased detection of slightly haemolysed samples is having on repeat biochemistry requests, especially for potassium, we are changing the haemolysis level at which a repeat sample is advised for certain tests. This will not have any impact on the clinical validity of results.

From 1st November 2021, you should see fewer repeat requests in slightly haemolysed samples for the following biochemistry tests:
• Potassium
• BNP
• Creatine Kinase (CK)
• Uric acid (urate)

Please contact Cat Dibden if you have any queries about this change.

Published on Wednesday 30 May 2022 by Jayshree Sisodia